Demand- and supply-side determinants of diphtheria-pertussis-tetanus nonvaccination and dropout in rural India

Arpita Ghosh,Ramanan Laxminarayan

doi:10.1016/j.vaccine.2016.12.024

Arpita Ghosh, Ramanan Laxminarayan

Open Access

https://doi.org/10.1016/j.vaccine.2016.12.024

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Abstract

BackgroundAlthough 93% of 12- to 23-month-old children in India receive at least one vaccine, typically Bacillus Calmette–Guérin, only 75% complete the recommended three doses of diphtheria-pertussis-tetanus (DPT, also referred to as DTP) vaccine. Determinants can be different for nonvaccination and dropout but have not been examined in earlier studies. We use the three-dose DPT series as a proxy for the full sequence of recommended childhood vaccines and examine the determinants of DPT nonvaccination and dropout between doses 1 and 3. MethodsWe analyzed data on 75,728 6- to 23-month-old children in villages across India to study demand- and supply-side factors determining nonvaccination with DPT and dropout between DPT doses 1 and 3, using a multilevel approach. Data come from the District Level Household and Facility Survey 3 (2007–08). ResultsIndividual- and household-level factors were associated with both DPT nonvaccination and dropout between doses 1 and 3. Children whose mothers had no schooling were 2.3 times more likely not to receive any DPT vaccination and 1.5 times more likely to drop out between DPT doses 1 and 3, compared with children whose mothers had 10 or more years of schooling. Although supply-side factors related to availability of public health facilities and immunization-related health workers in villages were not correlated with dropout between DPT doses 1 and 3, children in districts where 46% or more villages had a healthcare subcentre were 1.5 times more likely to receive at least one dose of DPT vaccine compared with children in districts where 30% or fewer villages had subcentres. ConclusionsNonvaccination with DPT in India is influenced by village- and district-level contextual factors over and above individuals’ background characteristics. Dropout between DPT doses 1 and 3 is associated more strongly with demand-side factors than with village- and district-level supply-side factors.

Highlights

Coverage with the third dose of diphtheria-pertussis-tetanus vaccine (DPT3) is a widely used indicator of the performance of countries’ routine immunization services [1,2]
Only 40% and 14% of the villages have subcentres and primary health centre (PHC), respectively, 84% of the villages are connected by road to a subcentre or PHC
High dropout rates coupled with high DPT1 coverage suggest that many mothers who visit a health facility for dose 1 but do not return for the subsequent ones may be dissatisfied with the services or not made aware that three doses are needed

Summary

Introduction

Coverage with the third dose of diphtheria-pertussis-tetanus vaccine (DPT3) is a widely used indicator of the performance of countries’ routine immunization services [1,2]. We use the three-dose DPT series as a proxy for the full sequence of recommended childhood vaccines and examine the determinants of DPT nonvaccination and dropout between doses 1 and 3. Methods: We analyzed data on 75,728 6- to 23-month-old children in villages across India to study demand- and supply-side factors determining nonvaccination with DPT and dropout between DPT doses 1 and 3, using a multilevel approach. Supply-side factors related to availability of public health facilities and immunization-related health workers in villages were not correlated with dropout between DPT doses 1 and 3, children in districts where 46% or more villages had a healthcare subcentre were 1.5 times more likely to receive at least one dose of DPT vaccine compared with children in districts where 30% or fewer villages had subcentres.

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